Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1060_Библиотеки_им_академика_М_И_Перельмана
.pdf
Examination of Peripheral Nervous System
https://t.me/med1917
in brachial plexus or median nerve injuries. In the
lower limb it can be seen in sciatic nerve or tibial
nerve distribution. Clinically, there will be hyperaesthesia and severe, disabling burning pain along the
distribution of the nerve.
Median Nerve Injury
Median nerve arises from lateral (C
cord (C8 and T1) of the brachial plexus. It is initially
lateral to the axillary artery and becomes medial in
the lower part of the arm and in the cubital fossa.
It passes through the two heads of the pronator teres,
descends in relation to flexor muscles (deep to flexor
digitorum superficialis and superficial to flexor
digitorum profundus); later over the lateral edge of
the flexor digitorum superficialis and between it and
flexor carpi radialis. It enters the palm through the
carpal tunnel at the wrist. It supplies pronator teres,
flexor carpi radialis, palmaris longus and flexor
digitorum superficialis. Anterior inerosseous branch
of the median nerve supplies pronator teres, lateral
half of the flexor digitorum profundus, flexor pollicis
longus and pronator quadratus. In the wrist, it supplies
abductor pollicis brevis, flexor pollicis and opponens
pollicis of thenar eminence and lateral two lumbricals.
It gives sensory supply to lateral three and half fingers
of the hand.
Median nerve is affected in: 1.Injuries - Supracondylar
fracture of the elbow; Fracture-dislocation of the
elbow; Direct cut injuries. 2. Leprosy; 3. Carpal tunnel
syndrome; 4. As a part of brachial plexus injury.
) and medial
5, 6, 7
211
ulnar side when flexed against resistance. In low
median nerve palsy- Flexor digitorum profundus is
not paralysed and so pointing index is not seen. Loss
of action of opponens pollicis is seen (Figs 8.22 and
8.23).
Fig. 8.22: Nerves of forearm – ulnar, median, radial
and their branches.
Clinical features of median nerve palsy: In high median
nerve palsy—Wasting of the thenar eminence; loss
of sensation in lateral three and half fingers; Ochsner’s
clasping test shows pointing index because of the
inactivity of flexor digitorum superficialis and lateral
two divisions of the profundus; ‘Ape or Simian thumb
deformity’ is due to overaction of the adductor pollicis
which is supplied by the deep branch of ulnar nerve.
As all other thenar muscles are paralysed, thumb comes
in the same plane of the metacarpals. ‘Pen test’: In
median nerve injury, pen held in front of the hand
cannot be touched by thumb as abduction is not possible
due to paralysis of the abductor pollicis brevis. Flexor
carpi radialis is paralysed and so hand deviates towards
Fig. 8.23: Sensory loss in median nerve injury.
212
https://t.me/med1917
SRB’s Clinical Surgery
Fig. 8.24: Anatomy of carpal tunnel.
Carpal Tunnel Syndrome
It is the compression neuropathy of median nerve in
the carpus, deep to flexor retinaculum (osseo fibrous
tunnel/canal). It is actually a stenosing tenosynovitis/
tenovaginitis under the flexor retinaculum. Flexor
retinaculum (transverse carpal ligament) maintains the
concavity of wrist and extends laterally from trapezium
and scaphoid to pisiform and hook of the hamate
medially. Carpal tunnel is formed by carpal bones
behind and flexor retinaculum in front. It contains
median nerve and long flexor tendons of fingers and
thumb. Ulnar nerve lies superficially, not in the carpal
tunnel. Median nerve gets compressed if space of the
carpal tunnel gets reduced (Fig. 8.24).
Causes—Lunate dislocation; malunited Colles’ fracture; radiocarpal arthritis; flexor tendon tenosynovitis;
myxoedema; acromegaly; pregnancy.
Clinical features—Common in females; where there
is tingling, numbness, paraesthesia and burning
sensation in the lateral three and half fingers supplied
by median nerve; burning sensation gets aggravated
at night and Ape thumb deformity, wasting of thenar
muscles, weakness of opponens pollicis and abductor
pollicis brevis are other features of low median nerve
palsy . When BP cuff is inflated patient feels the typical
pain in the fingers; tapping the median nerve at the
distal end of forearm with the wrist held in extension
aggravates the symptoms; condition is often bilateral.
There is also difficulty in flexing the fingers with pain.
Often mild tenderness over the flexor retinaculum may
be elicited. Symptoms exacerbate at night typically.
Pressure on the retinaculum does not induce the
symptoms; but flexing the wrist fully and holding in
that position for 2 minutes produce symptoms. Light
touch and two point discrimination is affected in the
3½ fingers and palm. There is loss of muscle bulk
of thenar eminence which is easily felt when these
muscles are contracted. There are no features of arterial
insufficiency (Refer Chapter 30, pg 686).
Differential diagnosis—Cervical spondylosis; cervical
rib syndrome. Diagnosis is by nerve conduction
studies.
Ulnar Nerve Injury
After arising from the medial cord of the brachial plexus
(C8 and T1), it runs on the medial aspect of the axillary
artery up to middle of the arm. Then it enters the
posterior compartment in relation to triceps muscle.
After passing behind the medial epicondyle along with
superior ulnar collateral artery and through two heads
of flexor carpi ulnaris, it runs in front of the flexor
digitorum profundus (FDP) in the forearm. It reaches
the hand in front of the flexor retinaculum through
Guyon’s canal. It stays between pisiform bone medially
and ulnar artery laterally. Here it divides into superficial
and deep branches.
Ulnar nerve supplies flexor carpi ulnaris, medial
half of flexor digitorum profundus, all muscles of the
Examination of Peripheral Nervous System
https://t.me/med1917
hypothenar eminence (palmaris brevis, abductor digiti
minimi, opponens digiti minimi, and flexor digiti
minimi), and adductor pollicis of the thenar eminence,
3rd and 4th lumbricals and all interossei of the hand.
It also gives sensory supply to medial part of the hand,
medial one and half fingers. Ulnar nerve is affected
in: Supracondylar fracture; injury to the medial
epicondyle; tardy ulnar palsy (entrapment neuropathy
behind the medial epicondyle); leprosy; cubitus valgus
deformity.
Clinical Features
Claw hand deformity along with weakness of all the
muscles supplied by the ulnar nerve is seen; Card test:
A card is placed between the two fingers of the patient
to grasp. In weak palmar interossei, patient can not
grasp (palmar interossei are adductors of the fingers—
PAD). Abduction of fingers is also checked (dorsal
interossei are abductors) (DAB). Froment’s sign: A
book is placed to grasp between fingers and thumb
of the patient. Normally thumb will be straight because
of the action of adductor pollicis muscle. Because it
is paralysed in ulnar palsy, grasp is achieved by action
of flexor pollicis longus and there will be flexed thumb.
Loss of sensation over medial one and half fingers
and hand is seen (Fig. 8.25).
213
Intrinsic plus deformity: It is due to muscle contracture
and fibrosis.
Ulnar paradox: In ulnar palsy higher the lesions, lesser
the deformity, lower the lesion, more the deformity.
In higher lesion, FDP is also paralysed. In lower lesion
FDP is intact and so FDP causes more flexion (over
action) and so aggravates the claw hand.
Claw Hand
It is the hyperextension of the metacarpophalangeal
joint with flexion of the interphalangeal joints of the
hand. Extension of MCP joint is due to action of
extensor digitorum; Flexion of MCP joint and extension of interphalangeal joints are by (through extensor
hood) interossei and lumbricals (Main en griffe). So
extensor hood is functioned by ulnar nerve mainly
and also by median nerve (Figs 8.26A and B). In ulnar
or median nerve palsies, these actions are paralysed
and so patient develops claw hand. It is actually
intrinsic minus deformity.
Intrinsic minus deformity: It is due to loss of intrinsic
muscle power, i.e. claw hand.
Fig. 8.25: Sensory loss in ulnar nerve injury.
A
A
Figs 8.26A and B: Ulnar claw hand with hyperextension
of metacarpophalangeal joints and flexion of proximal and
distal interphalangeal joints in medial two fingers due to
ulnar nerve palsy.
214
https://t.me/med1917
SRB’s Clinical Surgery
Causes: Leprosy; trauma; entrapment neuropathies;
tardy ulnar palsy; Klumpke’s palsy and rare causes
(like syringomyelia, poliomyelitis, amyotrophic lateral
sclerosis, Volkmann’s contracture). Causes may be
neurological or musculoskeletal. Claw hand is a
deformity occurring due to loss of motor function;
but often there will be associated sensory loss also.
Clinical Features: Typical claw hand; Loss of
sensation along the distribution of the nerve; inability
to grasp card between the fingers; while holding the
book between the thumb and fingers, thumb will be
flexed in ulnar claw hand (Froment’s test).
Types: 1. Ulnar claw hand: Only medial two fingers
are involved. a) Low ulnar palsy: Here lesion is in the
wrist (at Guyon’s canal). Here deformity is more
because of the over action of the FDP. b) High ulnar
palsy: Here FDP is also paralysed and over action is
not there. So deformity is lesser. Ulnar paradox:
Higher the lesion lesser the deformity , lower the lesion
A
more the deformity . 2. Median claw hand: Only lateral
two fingers are involved. It is less common. 3.
Combined median and ulnar claw hand: Here all four
fingers of the hand are involved (Figs 8.27A and B).
Radial Nerve Lesions
Radial nerve is derived from the posterior cord of
the brachial plexus (C
the axillary artery in front of the subscapularis,
latissimus dorsi and teres major. It passes through the
medial and lateral heads of the triceps muscle, winds
round the humerus through the radial groove and enters
the forearm in front of the lateral epicondyle and in
relation to brachioradialis, brachialis and extensor
carpi radialis longus muscles. In the arm it supplies
triceps, anconeus, brachioradialis, extensor carpi
radialis longus and part of the brachialis. It gives
posterior and lower lateral cutaneous nerves of the
arm and posterior cutaneous nerve of he forearm.
Superficial branch of the radial nerve from the elbow
runs in the forearm in relation to supinator and
brachioradialis and ends by forming 5 digital nerves
which gives sensory supply to lateral side of the thumb,
related part of thenar eminence, three and half fingers
on the dorsal aspect (upto the root of the nail, upto
the middle phalanx of the index finger, upto the
proximal interphalangeal joints of the middle and ring
fingers). Deep branch also called as posterior
inerosseous nerve winds round the radius supplying
supinator and extensor carpi radialis brevis. It gives
3 short branches to extensor digitorum, extensor digiti
minimi and extensor carpi ulnaris. It also gives two
long branches (One to abductor pollicis longus and
extensor pollicis brevis; another extensor pollicis
longus and extensor indicis).
and T1). It descends behind
5, 6, 7, 8
B
Figs 8.27A and B: Combined claw hand involving all
fingers due to both ulnar and median nerve injuries.
Conditions where radial nerve is affected: In the
axilla—Crutch palsy: It is neuropraxia; due to fracture
upper end of the humerus; bony or soft tissue growth.
In the radial groove—Pressure on the arm from the
edge of the operating table; Saturday night palsy:
An individual with excessive alcohol consumption
compresses his arm over the chair or by fall. It is
neuropraxia. Prolonged tourniquet application—
tourniquet palsy. Fracture of the shaft of the humerus.
Rarely intramuscular injection of drugs can cause
Examination of Peripheral Nervous System
https://t.me/med1917
radial nerve palsy. In the elbow – due to dislocation
or fracture neck of the radius.
Clinical features: Wrist dr op due to inability to extend
the wrist; inability to extend metacarpophalangeal
joint, but extensions of the interphalangeal joints are
normal; inability to extend the forearm; inability to
extend the thumb; flexion of the elbow against
resistance with forearm in mid-prone position is
difficult because of the weakness of the brachioradialis
muscle; loss of sensation in back of the arm, forearm,
hand and lateral three and half fingers (Fig. 8.28).
Posterior interosseous nerve is purely motor and
so when it gets injured the sensation is intact.
Brachioradialis is supplied by radial nerve not by
posterior interosseous nerve and so its action is intact
which can be confirmed by checking against resistance.
A
Figs 8.29A and B: Sensory loss seen in lateral
popliteal nerve/common peroneal nerve palsy.
215
B
Fig. 8.28: Sensory loss in radial nerve injury.
Common Peroneal Nerve
This nerve supplies the extensor and peroneal group
of muscles and sensory supply to the skin over the front
and lateral aspect of the leg and dorsum of the foot.
Common peroneal nerve is affected by—fracture
neck of the fibula; leprosy; lead poisoning; iatrogenic.
Clinical features: Foot drop with high stepping gait;
talipes equino-varus deformity; loss of sensation in
the lateral side of the leg and dorsum of the foot (Figs
8.29A to 8.30C).
Figs 8.30A to C: Sensory nerve supply of foot, sole
with sole dermatomes.
216
https://t.me/med1917
Foot Drop
Inability to dorsiflex and evert the foot due to paralysis
of the peroneal and extensor group of muscles
following injury to common peroneal nerve.
Causes: Fracture neck of the fibula; leprosy; lead
poisoning; iatrogenic; direct incised wound.
Clinical features: High stepping gait; loss of sensation
over lateral and dorsum of the foot.
SRB’s Clinical Surgery
Axillary Nerve Injury
Axillary nerve supplies the deltoid and teres minor
muscle and also sensory supply to the skin over the
upper lateral aspect of the arm. Axillary nerve is
affected by—Fracture neck of the humerus; dislocation
of humeral head; following intramusclular injection
into the deltoid. Clinically there will be loss of
abduction of the shoulder and anaesthesia of the skin
over the lateral part of the arm.
Medial Popliteal Nerve
It supplies the soleus, gastrocnemius, popliteus,
plantaris, tibialis posterior, flexor digitorum longus
and flexor hallucis longus. Medial popliteal nerve is
rarely involved by any disease process. Trauma can
cause medial popliteal nerve palsy. It is rarely involved
except in open wounds.
Clinical features: Inability to plantar flex the foot;
claw toes; loss of sensation in the sole of the foot
(Fig. 8.31).
Fig. 8.31: Diagram showing sensory distribution of
posterior aspect of the leg.
Long Thoracic Nerve Injury
(Nerve of Bell)
It supplies Serratus anterior muscle. It arises from
C
cervical roots. The nerve is injured commonly
5, 6, 7
in malignancy, during breast, axillary or chest wall
surgeries. Often it is injured in severe brachial plexus
injury. Clinically, when outstretched (elbow extended)
arm is pushed against the wall, the inferior angle of
the scapula will become prominent (Winging of the
scapula) (Figs 8.32A and B).
Accessory Nerve Injury
It is 11th cranial nerve having cranial and spinal roots.
Cranial part begins at nucleus ambiguous and is
distributed through vagal branches to muscles of palate,
pharynx, and larynx. Spinal root begins from long
spinal nucleus of the spinal cord between C1 and C5.
It emerges as 5 roots from the spinal cord join to form
spinal root of accessory nerve. It runs upwards to reach
the foramen magnum (enters it behind the vertebral
artery); joining cranial root which again gets separated.
Cranial root after separation joins vagus below inferior
vagal ganglion. Spinal root prior to separation from
cranial root runs upwards and laterally along with 9th
and 10th cranial nerves crossing jugular tubercle
reaching the jugular foramen and leaving the cranium
through it. Nerve descends between internal jugular
vein and internal carotid artery, deep to parotid and
styloid process, reaching between angle of mandible
and mastoid process, reaching deep of sternomastoid
muscle superficial to internal jugular vein. It is crossed
by occipital artery and accompanied by sternomastoid
branch of occipital artery. At the junction of upper
1/4th and lower 3/4th it pierces the anterior border
of the sternomastoid muscle, emerging through the
Examination of Peripheral Nervous System
https://t.me/med1917
A
A
217
B
Figs 8.32A and B: Winging of scapula is injury to long thoracic
nerve of Bell—paralysing the serratus anterior muscle.
posterior border into the posterior triangle; entering
the anterior margin of the trapezius 5 cm above the
clavicle. It is communicated with spinal nerves on
the deep surfaces of both sternomastoid and trapezius
muscles through C
sternomastoid and trapezius muscles. Nerve may be
affected in advanced secondaries in neck; block
dissection (radical) of the neck (Figs 8.33A and B).
Clinically , there will be wasting of trapezius muscle;
drooping of the shoulder; inability to elevate the
shoulder against resistance. Sternomastoid also can
2, 3
and C
roots. Nerve supplies
3, 4
B
Figs 8.33A and B: Accessory nerve anatomy (11th cranial
nerve). Wasting of trapezius and inability to shrug the shoulder
are the typical features of accessory nerve injury.
be checked for power by turning the patient neck to
opposite side against resistance.
Hypoglossal Nerve Injury
It is 12th cranial nerve arising from hypoglossal nucleus
of medulla in the floor of the 4th ventricle as 10-15
roots which soon joins to form 2 bundles which later
join to form single trunk. It comes out of the skull
through hypoglossal canal/anterior condylar canal
of occipital bone; it travels initially deep to internal
jugular vein, later between internal jugular vein and
218
https://t.me/med1917
Different joints with their innervation and various muscle actions
Shoulder Flexion C
Extension C
Abduction C
Adduction Pectoralis major, latissimus dorsis, biceps
Elbow Flexion C
Extension C
Wrist Flexion C
Extension C
Abduction Flexor carpi radialis, extensor carpi radilalis longus and brevis,
Adduction Flexor carpi ulnaris, extensor carpi ulnaris
Hip Flexion L
Extension L
Abduction L
Adduction L
Medial rotation Tensor fascia lata, anterior fibres of gluteus medius and minimus
Lateral rotation Two obturators, two gemelli, quadratus femoris
Knee Flexion L
Extension L
Ankle Dorsiflexion L
Plantar flexion L
Foot Inversion (is more L
than eversion)
Eversion L
SRB’s Clinical Surgery
5,6
5,6
5,6
5,6
6,7,8
6,7,8
6,7,8
2,3,4
, S
5
, S
4,5
2,3,4
, S
4,5
2,3,4
, S
4,5
5, S1,2
4,5
, S
5
1,2
1
1,2
1
1
Nerve to pectoralis major, circumflex nerve to deltoid
Thoracodorsal nerve – latissimus dorsi
Deltoid muscle – axillary nerve
Brachialis, biceps, brachioradialis – musculocutaneous nerve
Triceps, anconeus – radial nerve
Flexor carpi radialis, flexor carpi ulnaris – median and ulnar nerves
Extensor carpi radialis longus, extensor carpi radialis brevis,
extensor carpi ulnaris – radial nerve
abductor pollicis longus and extensor pollicis brevis
Psoas major, iliacus – lumbar and femoral nerves
Gluteus maximus and hamstrings – inferior gluteal nerve
Gluteus medius and minimus – superior gluteal nerve
Adductor longus, brevis, magnus – obturator nerve
Biceps femoris, semitendinosus, semimembranosus – sciatic nerve
Quadriceps femoris – femoral nerve
Tibialis anterior – deep peroneal nerve (anterior tibial nerve)
Gastrocnemius and soleus – posterior tibial nerve (tibial nerve)
Tibialis anterior and tibialis posterior
Peroneus longus and peroneus brevis – superficial peroneal nerve
internal carotid artery, descending in relation to front
of vagus, deep to parotid, styloid process, and posterior
belly of digastric, stylohyoid, posterior auricular and
occipital arteries. Near lower margin of the posterior
belly of digastric, it curves anteriorly hooking lower
sternomastoid branch of occipital artery; crossing
internal and external carotid arteries, loop of lingual
artery; running deep to posterior belly of digastric
reaching submandibular salivary gland. It passes on
the hyoglossus and geniglossus deep to submandibular
salivary gland and mylohyoid to reach the tongue.
It is communicated by fibres from C1 spinal nerve.
It supplies all intrinsic and extrinsic muscles of the
tongue except palatoglossus which is supplied by
cranial part of accessory nerve through vagus. C
component gives meningeal branch supplying the
meninges of anterior part of posterior cranial fossa.
C1 also supplies thyrohyoid and geniohyoid muscles;
its descending hypoglosii branch forms upper root of
ansa cervicalis. Nerve can be affected in advanced
neck secondaries, malignant submandibular salivary
gland, radical neck dissection and submandibular
salivary gland excision surgery . When it is involved,
there will be wasting of the tongue on that side; while
protruding outwards, tongue will deviate towards same
side (Fig. 8.34).
1
Fig. 8.34: Hypoglossal nerve palsy. Here tongue deviates
towards same side. Wasting of tongue muscles on the same
side is evident.
Examination of Muscles, Tendons and Fasciae
https://t.me/med1917
Examination of
Muscles, Tendons
219
9
Sound clinical knowledge of muscle and tendon
diseases is essential. It also needs a good anatomical
knowledge of the muscle, its origin, insertion, actions
and nerve supply.
History
Pain: Pain is the main feature in degenerative diseases
of the tendons, muscles, ligaments or fasciae. Pain
in epicondyles in tennis elbow (lateral) or Golfer’s
elbow (medial) is common. Pain of the tendon is felt
in tendonitis like patellar or Achilles’ tendons. In
tenosynovitis, pain is felt along the tendon like de
Quervain’s tenosynovitis. Rest pain along the distribution of the median nerve is common in carpal tunnel
syndrome.
Deformity is the symptom as well as the inspectory
finding. Patients always observe the deformity and
tell in the history.
General Examination
Pallor and other associates relevant features should
be looked for along with nutrition, neurological
examination, etc. Specific deformities are seen often
in conditions like leprosy.
Local Examination (Look/Feel/
Measure/Move)
Inspection
Deformity is the commonest and specific for certain
conditions. In Dupuytren’ s contractur e there is flexion
of ring and little fingers. Volkmann’s ischaemic
contracture causes extension of wrist and metacarpophalangeal joints with flexion of interphalangeal
and Fasciae
joints. When the wrist is fully flexed, fingers can be
extended – Volkmann’s sign.
Swelling is seen in torn muscle. T enosynovitis causes
swelling of the tendon.
Skin over the area or swelling for scar/colour/oedema/
sinuses/asymmetry , abnormal wrinkles, etc. should be
asked for.
Wasting of the muscles should be inspected. Shape,
wasting, hypertrophy , irregularity, displacement of the
muscle should be looked for. Muscle should be
inspected at rest as well as with contraction. It should
be compared to other muscles and opposite side
muscles.
Length of the limb, discrepancies on inspection should
be observed and noted.
Palpation
Look for rise in skin temperature/presence of pitting
when oedema is there.
Tenderness is elicited at the sites of the degenerative
pathology whether it is epicondylitis or tendinitis.
Palpation of the swelling for all its features like any
other swelling (see Chapter 3 on Swelling) should be
carried out.
Measure the real and apparent lengths of the limb
and compare to opposite side.
Muscle should be palpated at rest as well as with
contraction. When muscle is at rest intramuscular
swelling moves in right angle to the length of the
muscle; when muscle is contracted intramuscular lump
becomes immobile. Ruptured muscle when felt will
220
https://t.me/med1917
SRB’s Clinical Surgery
be tender often with a swelling. There will be a
depression when relaxed; but a firm swelling over the
edge of the ruptured muscle with a sharp depression
at the site of tear is typical on contraction. Haematoma
may be felt in a ruptured muscle.
Movements of the joints: Active movement is the one
which patient does and shows to the examiner; whose
range, abnormal mobility or restrictions should be
observed. Passive movement is the one which examiner
elicits using his hands.
Neurological Examination
Neurological examination should be done like in carpal
tunnel syndrome for median nerve palsy . Motor power
and reflexes should be checked.
Peripheral pulses should be examined for blood
supply.
Relevant Systemic Examination
Relevant systemic examination is a must.
Carpal Tunnel Syndrome
It is the classical example of stenosing tenosynovitis.
Refer for detail Chapter 8, pg 212.
Stenosing Tenosynovitis/Tenovagintis
Trigger finger: It is of unknown aetiology wherein
extension of the affected finger is difficult; finger gets
‘locked’ fully in flexed position; flexed finger can be
extended with a ‘sudden click’ like a trigger of a pistol
using excessive effort often with other hand. It is
common in middle aged women. There will be a
thickened nodule in the long flexor tendon sheath
adjacent to head of the metacarpal or constricting band/
ring in the synovial sheath. It is common in middle
aged women. It is not painful even on clicking. Finger
gets stuck in flexed position and unable to extend.
It is commonly seen in middle or ring finger. Finger
looks normal. Sensation is normal. It is not associated
with any systemic musculoskeletal diseases. Trigger/
snapping thumb: It is rare; seen in neonates and infants;
affecting thumb with a similar snap. An orange pip
like swelling may be felt over the head of the first
metacarpal bone. de Quervain’s stenosing tenosyno-
vitis: It involves the common tendon sheath of the
abductor pollicis longus and extensor pollicis brevis.
Bulge may be seen or felt over the radial styloid process
or anatomical snuff box. There is difficulty in abducting
and extending the thumb. Adduction of thumb is
painful.
Congenital Contracture of Little Finger
It is commonly a bilateral condition; seen in childhood;
with contracture of soft tissues; mimics Dupuytren’s
contracture but palmar aponeurosis is normal and ring
finger is not involved. Here first phalanx is hyperextended, middle and terminal phalanges are flexed.
Straightening of the finger may not be possible.
Dupuytren’s Contracture
It is localised thickening of palmar aponeurosis with
fibrous nodule formation causing flexion of ring and
then little fingers. Terminal phalanx is not affected
as palmar aponeurosis does not extend into terminal
phalanx. It begins at and mainly involves medial aspect
of the palmar aponeurosis. Eventually all fingers may
get involved; joints also may be involved causing
arthritis and stiff joints. Skin gets adherent to thickened
palmar aponeurosis. It is often familial and bilateral
(45%). It is common in males (10 times). Pain is not
common; but stiffness is usual. Taut fibrous strands
are seen and felt especially along the line of ring and
little fingers. By flexing the wrist flexion deformity
will not get reduced. Garrod’s pads of fat develop
over the knuckles of proximal interphalangeal joints.
Dupuytren’s contracture is often associated with –
plantal fasciitis (5%; Lederhose’s disease); mediastinal
and retroperitoneal fibrosis; Peyronie’s disease of penis
(3%); nodules in the face and ear; Pellegrini Steida’s
disease (Myositis ossificans with calcification of
commonly superior part of medial collateral ligament
of knee joint). Galezia triad is Dupuytren’ s contracture; retroperitoneal fibrosis; Peyronie’s diseases of
penis. Dupuytren’s contracture may be due to repeated
minor trauma, cirrhosis, alcoholism, epileptics on
phenytoin therapy, diabetes mellitus and other
metabolic conditions. It can be often familial – autosomal dominant. Condition causes restriction of hand
function and arthritis of joints (Figs 9.1A and B).
Burns Contracture of the Finger
It causes permanent contracture of fingers and wrist.
History of burn injury will be present (Fig. 9.2).
Соседние файлы в папке Библиотека им академика М.И. Перельмана